A US woman who shot and killed her husband and two adult children before taking her own life is thought to have committed the shocking crime as a result of being ostracised from the religion she was raised in.

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With the plan hanging by a thread, Trump was acutely aware that McCain's vote would be a deciding factor.

What he failed to predict was that the 80-year-old -- in the twilight of his career -- would stun the political world and side with Trump's opponents, bringing the president's campaign pledge to repeal and replace Obamacare crashing to the ground.

"We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of the aisle, heed the recommendations of the nation's governors, and produce a bill that finally delivers affordable health care for the American people," he said.

"We must do the hard work our citizens expect of us and deserve."

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Two days earlier, McCain had dramatically returned to Washington from Arizona, where he was recuperating after a shock brain cancer diagnosis, to cast one of the deciding votes to allow formal debate on health care to begin.

Then on Thursday, as the Republican effort to overhaul Obamacare hung in the balance, McCain spoke out about the bill's faults, warning it offered no workable replacement and could cause health care costs to spike for million

McCain made clear he is no fan of the Affordable Care Act, telling reporters "the status quo is not satisfactory."

But what Republicans were cooking up in its stead was not the answer for the senator from Arizona.

Two other Senate Republicans -- Susan Collins and Lisa Murkowski -- had long opposed the effort, and were likely to vote no. A third Republican defector would sink the bill.

Vice President Mike Pence was on hand after midnight to break the tie in the event of a 50-50 vote. He could be seen talking intently with McCain for more than 10 minutes on the Senate floor.

At the climax of the vote, McCain strode into the chamber's well at 1:29 am, caught the eye of the clerk, raised his right arm, and flashed a thumbs down.

Some Democrats in the chamber gasped and applauded. Republicans including Senate Majority Leader Mitch McConnell, the erstwhile commander of the anti-Obamacare plot, sat in stony silence as McCain turned and walked away.

It could well be the political exclamation point on McCain's sprawling career that saw him rise to become the 2008 Republican presidential nominee.

And the irony cannot be ignored that his vote preserved -- at least for now -- the deeply controversial reforms brought into being by the very politician who defeated him almost nine years ago.

Also unavoidable: recognition that McCain's "no" vote was a direct slight against the current president, someone whom McCain has never truly supported.

The feeling was mutual. In 2015 as he ran for president, Trump mocked McCain's war hero status as a former POW, sneering, "I like people who weren't captured."

Amid the messages of thanks by Democrats for their "hero" McCain, one stood out, from congressman Steve Cohen.

"Senator John McCain to Trump -- revenge is a dish best served cold," he tweeted.